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MHA/IHA HEN 2.0

HEN 2.0, v4.0 1 Last updated: 1/27/2016

Encyclopedia of Measures (EOM) Hospital Engagement Network (HEN) 2.0 – Program Evaluation Measures Adapted from Version 1.0 – AHA/HRET HEN 2.0

MHA/IHA HEN 2.0


Table of Contents Administrative Claims Data ......................................................................................................................... 3

Adverse Drug Event – Manifestations of Poor Glycemic Control ............................................................. 3

Birth Trauma – Injury to Neonate (PSI-17) ............................................................................................... 4

Vaginal Delivery with Instrument (PSI-18) ................................................................................................ 5

Vaginal Delivery without Instrument (PSI-19) .......................................................................................... 6

Preeclampsia – Maternal Morbidity ......................................................................................................... 7

Pressure Ulcer Rate, Stage 3+ (PSI-03) ..................................................................................................... 9

Readmission within 30 Days (All Cause) Rate ......................................................................................... 10

Post-Operative Sepsis (PSI-13) ................................................................................................................ 11

Post-Operative PE or DVT (PSI-12) .......................................................................................................... 12

National Healthcare Safety Network (NHSN) ............................................................................................ 13

Clostridium difficile (C. diff) LabID Event ................................................................................................ 13

Methicillin-resistant Staphylococcus aureus (MRSA) LabID Event ......................................................... 14

Catheter-Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio (SIR) ...................... 15

Catheter-Associated Urinary Tract Infection (CAUTI) Rate ..................................................................... 16

Urinary Catheter Utilization Ratio........................................................................................................... 17

Central Line-Associated Blood Stream Infection (CLABSI) Standardized Infection Ratio (SIR) ............... 18

Central Line-Associated Blood Stream Infection (CLABSI) Rate .............................................................. 19

Central Line Utilization Ratio .................................................................................................................. 20

Surgical Site Infection (SSI) Standardized Infection Ratio (SIR) .............................................................. 21

Surgical Site Infection (SSI) Rate ............................................................................................................. 22

Ventilator-Associated Condition (VAC) ................................................................................................... 23

Infection-Related Ventilator-Associated Complication (IVAC) ............................................................... 24

Keystone Data System (KDS)...................................................................................................................... 25

Adverse Drug Event – Excessive Anticoagulation with Warfarin – Inpatients ........................................ 25

Adverse Drug Event – Hypoglycemia in Inpatients Receiving Insulin ..................................................... 26

Adverse Drug Event – ADEs due to Opioids ............................................................................................ 27

Falls with Injury (NQF 0202) .................................................................................................................... 28

Early Elective Delivery (EED) ................................................................................................................... 29

Post-Partum Hemorrhage (PPH) ............................................................................................................. 30

MHA/IHA HEN 2.0


Administrative Claims Data

Adverse Drug Event – Manifestations of Poor Glycemic Control

ADE: MHA/IHA HEN 2.0 Evaluation Measure All Adverse Drug Events (ADE) – particularly as related to

Glycemic Management

Measure type Outcome Numerator Number of patients who experienced manifestations of poor glycemic

control during hospitalization, not present on admission. See included codes below.

Denominator Number of acute care inpatient discharges

Exclusions None

Rate calculation

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤ℎ𝑜 𝑒𝑥𝑝𝑒𝑟𝑖𝑒𝑛𝑐𝑒𝑑 𝑚𝑎𝑛𝑖𝑓𝑒𝑠𝑡𝑎𝑡𝑖𝑜𝑛𝑠 𝑜𝑓 𝑝𝑜𝑜𝑟 𝑔𝑙𝑦𝑐𝑒𝑚𝑖𝑐 𝑐𝑜𝑛𝑡𝑟𝑜𝑙

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑎𝑐𝑢𝑡𝑒 𝑐𝑎𝑟𝑒 𝑖𝑛𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠𝑥 100

Specifications/definitions Sources/Recommendations

Available from CMS - DHHS

Data source (s) Administrative Claims data

Automatic transfer from Inpatient database (MI and IL) Baseline period 2010

Data collection period Monthly, beginning January 2015 through March 2016 KDS Survey Name HEN - ADE - Manifestations of Poor Glycemic Control

KDS Measure ID(s) KDS-HEN-ADE-1 PfP Measure Name poor_glycemic

Patients experiencing the following codes as a secondary diagnosis: ICD-9-CM: Diabetic Ketoacidosis - 250.10-250.13 (MCC) Nonketotic Hyperosmolar Coma - 250.20-250.23 (MCC) Hypoglycemic Coma - 251.0 (CC) Secondary Diabetes with Ketoacidosis - 249.10-249.11 (MCC) Secondary Diabetes with Hyperosmolarity - 249.20-249.21 (MCC)

ICD-10-CM:

Diabetic Ketoacidosis – E11.69, E10.10, E11.65 Nonketotic Hyperosmolar Coma – E11.00, E11.01, E10.69, E11.65, E10.65 Hypoglycemic Coma – E15 Secondary Diabetes with Ketoacidosis – E08.10, E09.10, E13.10, E08.65 Secondary Diabetes with Hyperosmolarity – E08.01, E09.01, E13.00, E08.65

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/wPOAFactSheet.pdf

MHA/IHA HEN 2.0


Birth Trauma – Injury to Neonate (PSI-17)

All Facilities OB: MHA/IHA HEN 2.0 Evaluation Measure (AHRQ PSI 17)

Obstetrical (OB) Trauma - All newborns who have birth trauma

Measure type Outcome

Numerator Number of discharges among cases with codes for birth trauma in any diagnosis field. See included codes below.

Denominator Number of newborns. See excluded codes below.

Exclusions None

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠 𝑤𝑖𝑡ℎ 𝑎𝑑𝑚𝑖𝑛𝑖𝑠𝑡𝑟𝑎𝑡𝑖𝑣𝑒 𝑐𝑜𝑑𝑒 𝑓𝑜𝑟 𝑏𝑖𝑟𝑡ℎ 𝑡𝑟𝑎𝑢𝑚𝑎

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑛𝑒𝑤𝑏𝑜𝑟𝑛𝑠 𝑥 1,000


Available from AHRQ – PSI 17



Data collection period Monthly, beginning January 2015 through March 2016 KDS Survey Name HEN - OB PSI Measures KDS Measure ID(s) KDS-HEN-OB-1

PfP Measure Name PSI_17

ICD-9-CM: 767.0, 767.11, 767.3, 767.4, 767.5, 767.7, 767.8

ICD-10-CM: P10.0, P10.1, P10.4, P10.8, P10.9, P11.0, P11.1, P11.2, P11.3, P11.4, P11.5, P11.9, P12.2,

P13.0, P13.1, P13.2, P13.3, P13.8, P13.9, P14.2, P14.8, P14.9, P15.0, P15.1, P15.2, P15.3, P15.4, P15.5,

P15.6, P15.8

Denominator Exclusions: ICD-9-CM: 765.00, 765.01, 765.02, 765.03, 765.04, 765.05, 765.06, 765.07, 765.11, 765.12, 765.13, 765.14, 765.15, 765.16, 765.17, 767.6, 756.51 ICD-10-CM: P07.00, P07.01, P07.02, P07.03, P07.10, P07.14, P07.15, P07.16, P07.17, P14.0, P14.1, P14.3, Q78.0

*Codes from AHRQ: http://www.qualityindicators.ahrq.gov/icd10/

http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V45/TechSpecs/PSI%2017%20Birth%20Trauma%20Rate-Injury%20to%20Neonate.pdf

http://www.qualityindicators.ahrq.gov/icd10/

MHA/IHA HEN 2.0


Vaginal Delivery with Instrument (PSI-18)

All Facilities

OB: CMS HEN 2.0 Evaluation Measure (AHRQ PSI 18) Obstetrical (OB) Trauma - Vaginal Delivery with Instrument Measure type Outcome

Numerator Number of discharges, among cases meeting the inclusion and exclusion rules for the denominator, with any listed diagnosis codes for third and

fourth degree obstetric trauma. See included codes below.

Denominator Number of vaginal delivery discharges with any procedure code for instrument-assisted delivery. See included codes below.

Exclusions Discharges without any procedure code for instrument-assisted delivery

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 3𝑟𝑑 & 4𝑡ℎ 𝑑𝑒𝑔𝑟𝑒𝑒 𝑂𝐵 𝑡𝑟𝑎𝑢𝑚𝑎𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑣𝑎𝑔𝑖𝑛𝑎𝑙 𝑑𝑒𝑙𝑖𝑣𝑒𝑟𝑖𝑒𝑠𝑥1,000



Data source (s) Administrative Claims data Automatic transfer from Inpatient database (MI and IL) Baseline period 2010

Data collection period Monthly, beginning January 2015 through March 2016 KDS Survey Name HEN - OB PSI Measures KDS Measure ID(s) KDS-HEN-OB-2 PfP Measure Name PSI_18

Numerator: ICD-9-CM: 664.20, 664.21, 664.24, 664.30, 664.31, 664.34 ICD-10-CM: O70.2, O70.3

Denominator: ICD-9-CM: 72.0, 72.1, 72.21, 72.29, 72.31, 72.39, 72.4, 72.51, 72.53, 72.6, 72.71, 72.79, 72.8, 72.9 ICD-10-CM: 10D07Z3, 10D07Z4, 10D07Z5, 10D07Z6, 10D07Z8, 10S07ZZ


http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V44/TechSpecs/PSI%2018%20Obstetric%20Trauma%20Rate%20Vaginal%20Delivery%20With%20Instrument.pdf


MHA/IHA HEN 2.0


Vaginal Delivery without Instrument (PSI-19)

All Facilities

OB: CMS HEN 2.0 Evaluation Measure (AHRQ PSI 19) OB Trauma - Vaginal Delivery without Instrument Measure type Outcome

Numerator Number of discharges, among cases meeting the inclusion and exclusion rules for the denominator, with any listed diagnosis codes for third and

fourth degree obstetric trauma. See included codes below.

Denominator Number of vaginal delivery discharges identified by DRG or MS-DRG codes. See excluded codes below.

Exclusions Discharges with any procedure code for instrument-assisted delivery

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 3𝑟𝑑 & 4𝑡ℎ 𝑑𝑒𝑔𝑟𝑒𝑒 𝑂𝐵 𝑡𝑟𝑎𝑢𝑚𝑎𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑣𝑎𝑔𝑖𝑛𝑎𝑙 𝑑𝑒𝑙𝑖𝑣𝑒𝑟𝑖𝑒𝑠𝑥1,000


Available from AHRQ - PSI 19

Data source (s) Administrative Claims data Automatic transfer from Inpatient database (MI and IL) Baseline period 2010

Data collection period Monthly, beginning January 2015 through March 2016 KDS Survey Name HEN - OB PSI Measures KDS Measure ID(s) KDS-HEN-OB-3


Numerator: ICD-9-CM: 664.20, 664.21, 664.24, 664.30, 664.31, 664.34 ICD-10-CM: O70.2, O70.3

Exclusions: ICD-9-CM: 72.0, 72.1, 72.21, 72.29, 72.31, 72.39, 72.4, 72.51, 72.53, 72.6, 72.71, 72.79, 72.8, 72.9 ICD-10-CM: 10D07Z3, 10D07Z4, 10D07Z5, 10D07Z6, 10D07Z8, 10S07ZZ


http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50/TechSpecs/PSI_19_Obstetric_Trauma_Rate-Vaginal_Delivery_wo_Instrument.pdf


MHA/IHA HEN 2.0


Preeclampsia – Maternal Morbidity

All Facilities with OB services OB: MHA/IHA HEN 2.0 Evaluation Measure

Severe Maternal Morbidity Among Preeclampsia: Women diagnosed with preeclampsia with severe features and/or eclampsia

Measure type Outcome Numerator Number of cases among denominator population with a severe

maternal morbidity (SMM) code. See included codes below.

Denominator Number of mothers during their birth admission with one of the

administrative codes for Severe Preeclampsia, Eclampsia, or

Preeclampsia superimposed on pre-existing hypertension. See

included codes below.

Exclusions Ectopic pregnancies and miscarriages. See included codes below.

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓𝑐𝑎𝑠𝑒𝑠 𝑤𝑖𝑡ℎ 𝑆𝑀𝑀

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑤𝑜𝑚𝑒𝑛 𝑤𝑖𝑡ℎ 𝑎𝑑𝑚𝑖𝑛𝑖𝑠𝑡𝑟𝑎𝑡𝑖𝑣𝑒 𝑐𝑜𝑑𝑒𝑠 𝑟𝑒𝑙𝑎𝑡𝑖𝑛𝑔 𝑡𝑜 𝑝𝑟𝑒𝑒𝑐𝑙𝑎𝑚𝑝𝑠𝑖𝑎 𝑜𝑟 𝑒𝑐𝑙𝑎𝑚𝑝𝑠𝑖𝑎

𝑥 100


Available from Alliance for Innovations on Maternal Health (AIM)



Data collection period Monthly, beginning January 2015 through March 2016 KDS Survey Name HEN - OB Maternal Morbidity due to Preeclampsia KDS Measure ID(s) KDS-HEN-OB-4

PfP Measure Name SMM_HTN

Numerator: Cases having ICD-9-CM code of 642.5 or 642.6 or 642.7 and one of the following: ICD-9-CM SMM codes: 038, 31.1, 35, 36, 37, 39, 68.3‐68.9, 89.6, 96.01‐96.05, 96.7, 99.0, 99.6, 282.62, 282.64, 282.69 286.6, 286.9, 410, 415.1, 427.41, 427.42, 427.5 428.1, 430, 431, 432, 433, 434, 436, 437, 441, 518.4, 518.5, 518.81, 518.82, 518.84, 584, 642.6, 666.3, 668.0, 668.1, 668.2, 669.1, 669.3, 669.4, 670.2, 671.5, 673.0, 673.1, 673.2, 673.3, 673.8, 674.0, 785.5, 799.1, 800, 801, 803, 804, 851‐854, 860, 869, 995.0, 995.4, 995.91, 995.92, 997.1 997.2, 998.0 999.2, 93.90, ICD-9-PCS codes: 31.1,35.xx, 36.xx, 37.xx, 39.xx, 68.3-68.9, 89.6, 93.90, 96.01-96.05, 96.7, 99.0, 99.6

http://safehealthcareforeverywoman.org/downloads/AIM/AIM-Data-Metrics-v1-5.pdf

MHA/IHA HEN 2.0


Cases having ICD-10-CM codes (O1410, O1420, O1412, O1413, O1422, O1423, O159, O1502, O1503, O151, O152, O119, O111, O112, O113) and one of the following: ICD-10-CM SMM codes: C965, C966, D65, D688, D689, E71310, E71311 ,E71312, E71313, E71314, E71318, E7139, E7141, E7142, E7143, E71448, E7150, E71510, E71511, E71522, E71529, E71548, E803, E883, E8840, E8841, E8842, E8849, E8889, E889, H49819, I2109, I2111, I2119, I2129, I213, I214, I469, I4901, I4902, I7100, I7101, I7102, I7103, I711, I712, I713, I714, I715, I716, I718, I719, I97710, I97790, I9788, I9789, J80, J951, J952, J953, J95821, J95822, J9600, J9620, J9690, N170, N171, N172, N178, N179, O723, O754, O88111, O88112, O88113, O88119, O8812, O8813, O904, R092, S21309A, S26020A, S26021A, S26022A, S2610XA, S2690XA, S2691XA, S2692XA, S2699XA, S270XXA, S271XXA, S272XXA, S27309A, S27329A, S27339A, S27409A, S27809A, S27813A, S27819A, S27893A, S27899A, S279XXA, S31001A, S31609A, S3600XA, S36020A, S36021A, S36029A, S36030A, S36031A, S36032A, S3609XA, S36112A, S36113A, S36114A, S36115A, S36116A, S36118A, S36119A, S36129A, S3613XA, S36200A, S36201A, S36202A, S36209A, S3630XA, S36400A, S36408A, S36409A, S36500A, S36501A, S36502A, S36503A, S36508A, S36509A, S3660XA, S3681XA, S36899A, S3690XA, S37009A, S37019A, S37029A, S37039A, S37049A, S37059A, S37069A, S3710XA, S3720XA, S3730XA, S37409A, S37509A, S3760XA, S37819A, S37829A, S37899A, S3790XA Denominator: ICD-9-CM: 642.5, 642.6, 642.7 ICD-10-CM: O119, O111, O112, O113, O1410, O1412, O1413, O1420, O1422, O1423, O159, O1502, O1503, O151, O152

Exclusions:

ICD-9-CM: 630, 631, 632, 633, 634, 635, 636, 637, 638, 639 ICD-10-CM: A34, O000, O001, O002, O008, O009, O019, O021, O0281, O030, O031, O032, O0330, O0331, O0332, O0333, O0334, O0337, O0339, O034, O035, O036, O037, O0380, O0381, O0382, O0383, O0384, O0385, O0386, O0387, O0388, O0389, O039, O045, O046, O047, O0480, O0481, O0482, O0483, O0484, O0485, O0486, O0487, O0488, O0489, O070, O071, O072, O0730, O0731, O0732, O0733, O0734, O0735, O0736, O0737, O0738, O0739, O074, O080, O081, O082, O083, O084, O085, O086, O087, O0881, O0882, O0883, O0889, O089, Z332

MHA/IHA HEN 2.0


Pressure Ulcer Rate, Stage 3+ (PSI-03)

All Facilities

Pressure Ulcer: CMS HEN 2.0 Evaluation Measure (AHRQ PSI-03)

Pressure Ulcer Rate, Stages 3+


Numerator Number of patients with Stage III, Stage IV, or Unstageable Pressure Ulcers. See included codes below.

Denominator Number of surgical or medical discharges, for patients ages 18 years and older

Exclusions None

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤𝑖𝑡ℎ 𝑠𝑡𝑎𝑔𝑒 𝐼𝐼𝐼, 𝐼𝑉 𝑜𝑟 𝑢𝑛𝑠𝑡𝑎𝑔𝑒𝑎𝑏𝑙𝑒 𝑝𝑟𝑒𝑠𝑠𝑢𝑟𝑒 𝑢𝑙𝑐𝑒𝑟𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑜𝑟 𝑚𝑒𝑑𝑖𝑐𝑎𝑙 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠𝑥100


Available from AHRQ: PSI-03

Automatic transfer from Inpatient database (MI and IL)

NHSN data transfer No

Baseline period 2010

Data collection period Monthly, beginning January 2015 through March 2016

KDS Survey Name HEN - Pressure Ulcers PSI

KDS Measure ID(s) KDS-HEN-PrU-1


Numerator:

ICD-9-CM: 707.00-707.09, 707.23-707.25

ICD-10-CM: L89000, L89003; L89004; L89010, L89013; L89014; L89020; L89023; L89024; L89100; L89103;

L89104; L89110; L89113; L89114; L89120; L89123; L89124; L89130; L89133; L89134; L89140; L89143;

L89144; L89150; L89153; L89154; L89200; L89203; L89204; L89213; L89214; L89220; L89223; L89224;

L89300; L89303; L89304; L89310; L89313; L89314; L89320; L89323; L89324; L8943; L8944; L8945;

L89500; L89503; L89504; L89510; L89513; L89514; L89520; L89523; L89524; L89600; L89603; L89604;

L89610; L89613; L89614; L89620; L89623; L89624; L89810; L89813; L89814; L89890; L89893; L89894;

L8993; L8994; L8995; L89210


http://www.qualityindicators.ahrq.gov/Modules/PSI_TechSpec.aspx

http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V44/TechSpecs/PSI%2003%20Pressure%20Ulcer%20Rate.pdf


MHA/IHA HEN 2.0


Readmission within 30 Days (All Cause) Rate

All Facilities

Readmission: MHA/IHA HEN 2.0 Evaluation Measure Readmission within 30 Days (All Cause)

Readmissions to the same facility Readmissions to any facility


Numerator Number of inpatients returning as an acute care inpatient within 30 days of date of discharge - unplanned

Denominator Number of at-risk inpatient discharges Exclusions None

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓𝑢𝑛𝑝𝑙𝑎𝑛𝑛𝑒𝑑 𝑟𝑒𝑎𝑑𝑚𝑖𝑠𝑠𝑖𝑜𝑛𝑠 𝑤𝑖𝑡ℎ𝑖𝑛 30 𝑑𝑎𝑦𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑎𝑡 𝑟𝑖𝑠𝑘 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠 𝑥 100


Facilities should follow the CMS definition of an unplanned readmission. This definition is explained in the “Frequently asked questions” document, available from AHIMA or Quorum Health Resources Data source (s) Administrative Claims data

Automatic transfer from Inpatient database (MI and IL) Baseline period Q2 2011 – Q1 2012

Data collection period Monthly, beginning January 2015 through March 2016 KDS Survey Name HEN Readmissions KDS Measure ID(s) KDS-HEN-READ-1 (same facility)

KDS-HEN-READ-2 (any facility)

PfP Measure Name READ_INDEX READ_ANY

http://engage.ahima.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=6dd1620b-eb6e-4c76-b578-d97f0baf0d32

http://quality.knowledgebase.co/assets/riskstndoutcomemsrs_faqs_092013.pdf

http://quality.knowledgebase.co/assets/riskstndoutcomemsrs_faqs_092013.pdf

MHA/IHA HEN 2.0


Post-Operative Sepsis (PSI-13)

All Facilities

Sepsis: MHA/IHA HEN 2.0 Evaluation Measure (AHRQ PSI 13) Postoperative sepsis cases (secondary diagnosis) per 1,000 elective surgical discharges for patients

ages 18 years and older.

Measure type Outcome Numerator Number of discharges with diagnostic code for sepsis in any

secondary diagnosis field. See included codes below.

Denominator Number of elective surgical discharges age 18 and older defined by

administrative codes for an operating room procedure

Exclusions None

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠 𝑤𝑖𝑡ℎ 𝑎 𝑠𝑒𝑝𝑠𝑖𝑠 𝑑𝑖𝑎𝑔𝑛𝑜𝑠𝑖𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠 𝑥 1,000


Available from AHRQ PSI 13



Data collection period Monthly, beginning January 2015 through March 2016 KDS Survey Name HEN - Sepsis PSI KDS Measure ID(s) KDS-HEN-SEP-1


Numerator: ICD-9-CM: 038.0, 038.10, 038.11, 038.12, 038.19, 038.2, 038.3, 785.52, 998.00, 998.02, 038.40, 038.41, 038.42, 038.43, 038.44, 038.49, 038.8, 038.9, 995.91, 995.92.

ICD-10-CM: A02.1, A22.7, A26.7, A32.7, A40.0, A40.1, A40.3, A40.8, A40.9, A41.01, A41.02, A41.1, A41.2, A41.3, A41.4, A41.50, A41.51, A41.52, A41.53, A41.59, A41.81, A41.89, A41.9, A42.7, A54.86, B37.7, R65.20, R65.21, T81.10XA, T81.12XA *Codes from AHRQ: http://www.qualityindicators.ahrq.gov/icd10/

http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V50/TechSpecs/PSI_13_Postoperative_Sepsis_Rate.pdf


MHA/IHA HEN 2.0


Post-Operative PE or DVT (PSI-12)

All Facilities

PE/DVT: CMS HEN 2.0 Evaluation Measure (AHRQ PSI 12)

Number of surgical patients that develop a post-operative PE or DVT Measure type Outcome

Numerator

Number of discharges with administrative codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) in any secondary diagnosis field. See included codes below.

Denominator Number of surgical discharges age 18 and older defined by specific DRGs or MS-DRGs and an administrative code for an operating room procedure. See excluded codes below.

Exclusions None Rate calculation

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠 𝑤𝑖𝑡ℎ 𝑐𝑜𝑑𝑒 𝑓𝑜𝑟 𝐷𝑉𝑇 𝑜𝑟 𝑃𝐸

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑢𝑟𝑔𝑖𝑐𝑎𝑙 𝑑𝑖𝑠𝑐ℎ𝑎𝑟𝑔𝑒𝑠 𝑥 1,000



Data source(s) Administrative Claims data Automatic transfer from Inpatient database (MI and IL) Baseline period 2010

Data collection period Monthly, beginning January 2015 through March 2016 KDS Survey Name HEN - VTE PSI KDS Measure ID(s) KDS-HEN-VTE-1 PfP Measure Name PSI_12

ICD-9-CM: Deep Vein Thrombosis: 451.11, 451.19, 451.81, 453.40, 453.41, 453.42 Pulmonary Embolism: 415.11, 415.19, 415.13. Exclude patients in MDC 14 ICD-10-CM: Deep Vein Thrombosis: I80.10-I80.13; I80.201-I80.203; I80.209; I80.211-I80.213; I80.219; I80.221-I80.223; I80.229; I80.231-I80.233; I80.239; I80.291-I80.293; I80.299; I82.401-I82.403; I82.409; I82.411-I82.413; I82.419; I82.421-I82.423; I82.429; I82.431-I82.433; I82.439; I82.441-I82.443; I82.449; I82.491-I82.493; I82.499; I82.4Y1-I82.4Y3; I82.4Y9; I82.4Z1-I82.4Z3; I82.4Z9 Pulmonary Embolism: I26.02; I26.09; I26.92; I26.99 Denominator Exclusions: ICD-9-CM: 38.7 ICD-10-CM: 06H00DZ; 06H00DZ; 06H03DZ; 06H04DZ; 06L00CZ; 06L00DZ; 06L00ZZ; 06L03CZ; 06L03DZ; 06L03ZZ; 06L04CZ; 06L04DZ; 06L04ZZ; 06V00CZ; 06V00DZ; 06V00ZZ; 06V03CZ; 06V03DZ; 06V03ZZ; 06V04CZ; 06V04DZ; 06V04ZZ; *Codes from AHRQ: http://www.qualityindicators.ahrq.gov/icd10/

http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V45/TechSpecs/PSI%2012%20Perioperative%20Pulmonary%20Embolism%20or%20Deep%20Vein%20Thrombosis%20Rate.pdf


MHA/IHA HEN 2.0


National Healthcare Safety Network (NHSN)

Clostridium difficile (C. diff) LabID Event

NHSN Reporting Facilities ONLY C. diff: MHA/IHA HEN Evaluation Measure

C. diff LabID events at facility-wide inpatient level

Measure type Outcome Numerator Number of LabID C. diff Events Denominator Number of patient days

Exclusions Inpatient rehab facilities or inpatient psychiatric facilities with

separate CCN, and NICU/baby locations.

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐿𝑎𝑏𝐼𝐷 𝑒𝑣𝑒𝑛𝑡𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑑𝑎𝑦𝑠 𝑥 100


Available from CDC NHSN and CMS Hospital Compare

Data source (s) NHSN

Automatic transfer from NHSN- for hospitals conferring rights to IHA or MHA Keystone Center

Baseline period Hospital-dependent Data collection period Monthly, beginning July 2015

KDS Survey Name HEN - C.DIFF KDS Measure ID(s) KDS-HEN-CDIFF-1

PfP Measure Name NHSN_C_DIFF

Data elements to calculate this rate will be extracted from NHSN for hospitals which confer rights to IHA

or MHA Keystone Center. Critical Access Hospitals not reporting to NHSN will not be required to submit

this measure.

http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf

https://www.medicare.gov/hospitalcompare/search.html

MHA/IHA HEN 2.0


Methicillin-resistant Staphylococcus aureus (MRSA) LabID Event

NHSN Reporting Facilities ONLY

MRSA: MHA/IHA HEN 2.0 Evaluation Measure

MRSA LabID Events at facility-wide inpatient level Measure type Outcome

Numerator Number of LabID MRSA Events Denominator Number of patient days

Exclusions Inpatient rehab facilities or inpatient psychiatric facilities with

separate CCN number

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐿𝑎𝑏𝐼𝐷 𝑒𝑣𝑒𝑛𝑡𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑑𝑎𝑦𝑠 𝑥 100


Available from CDC NHSN and CMS Hospital Compare

Data source (s) NHSN

Automatic transfer from NHSN- for hospitals conferring rights to IHA or MHA Keystone Center Baseline period Hospital-dependent

Data collection period Monthly, beginning July 2015 KDS Survey Name HEN - MRSA KDS Measure ID(s) KDS-HEN-MRSA-1

PfP Measure Name NHSN_MRSA

Data elements to calculate this rate will be extracted from NHSN for hospitals which confer rights to IHA

or MHA Keystone Center. Critical Access Hospitals not reporting to NHSN will not be required to submit

this measure.

http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf

https://www.medicare.gov/hospitalcompare/search.html

MHA/IHA HEN 2.0


Catheter-Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio (SIR)


CAUTI: CMS HEN 2.0 Evaluation Measure – NHSN Reporting Facilities ONLY – NQF 0138 Catheter-associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio (SIR)

All: ICUs + Other Inpatient Units

ICU: ICUs excluding NICUs Measure type Outcome Numerator Number of observed infections Denominator Number of predicted infections Exclusions Non-indwelling catheters, NICU locations, expected infection count

less than one, or no data reported during baseline period.

SIR calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓𝑜𝑏𝑠𝑒𝑟𝑣𝑒𝑑 (𝑂)𝑖𝑛𝑓𝑒𝑐𝑡𝑖𝑜𝑛𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑥𝑝𝑒𝑐𝑡𝑒𝑑 (𝐸)𝑖𝑛𝑓𝑒𝑐𝑡𝑖𝑜𝑛𝑠


Available from CDC NHSN Available from National Quality Forum (NQF) 0138

Data source (s) NHSN (all inpatient locations) Automatic transfer from NHSN- for hospitals conferring rights to IHA or MHA Keystone Center

Baseline period Hospital-dependent

Data collection period Monthly, beginning July 2015 KDS Survey Name CAUTI SIR (HEN-Quarterly) KDS Measure ID(s) KDS-HEN-CAUTI-1a (all units)

KDS-HEN-CAUTI-1b (ICUs excluding NICUs)

PfP Measure Name NHSN_CAUTI_ALL_SIR NHSN_CAUTI_ICU_SIR

Notes This measure is only collected for hospitals submitting data to NHSN and conferring rights to IHA or MHA Keystone Center.

Data elements to calculate this ratio will be extracted from NHSN for hospitals which confer rights to IHA or MHA Keystone Center. Hospitals are expected to confer rights to all inpatient locations excluding Neonatal Intensive Care Units (NICUs). Critical Access Hospitals not reporting to NHSN will not be required to submit this measure.

Note: Only those locations for which baseline data have been published will be included in the SIR calculations. For acute care hospitals, the baseline time period is 2009; for long term acute care hospitals and inpatient rehabilitation facilities (IRFs) and IRF units, the baseline time period is 2013.

http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf

http://www.qualityforum.org/QPS/0138

MHA/IHA HEN 2.0


Catheter-Associated Urinary Tract Infection (CAUTI) Rate

All Facilities

CAUTI: CMS HEN 2.0 Evaluation Measure – All Facilities Catheter-associated Urinary Tract Infection (CAUTI) Rate


ICU: ICUs excluding NICUs Measure type Outcome Numerator Number of observed healthcare-associated CAUTI among patients in

bedded inpatient care locations.

Denominator Number of indwelling urinary catheter days for each location under surveillance for CAUTI during the data period.

Exclusions NICU locations

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓𝐶𝐴𝑈𝑇𝐼

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑎𝑡ℎ𝑒𝑡𝑒𝑟 𝑑𝑎𝑦𝑠𝑥 1,000


Available from CDC NHSN

Data source (s) NHSN (Keystone Data System for non-NHSN users)



Data collection period Monthly, beginning July 2015 KDS Survey Name CAUTI Data Collection KDS Measure ID(s) KDS-HEN-CAUTI-2a (all units)


PfP Measure Name NHSN_CAUTI_ALL_RATE NHSN_CAUTI_ICU_RATE

Data elements to calculate this ratio will be extracted from NHSN for hospitals which confer rights to IHA or MHA Keystone Center.

Hospitals not reporting to NHSN are required to report CAUTIs, patient days and urinary catheter days,

for all units through MHA Keystone Data System, monthly. Hospitals must report the numerators and

denominators for ICUs excluding NICUs, and also for ICUs (excluding NICUs) + all other inpatient units,

separately.


MHA/IHA HEN 2.0


Urinary Catheter Utilization Ratio

All Facilities

Data elements to calculate this ratio will be extracted from NHSN for hospitals which confer rights to IHA

or MHA Keystone Center.

Hospitals not reporting to NHSN are required to report urinary catheter days and patient days, for all units through MHA Keystone Data System, monthly. Hospitals must report the numerators and denominators for ICUs excluding NICUs, and also for ICUs (excluding NICUs) + all other inpatient units, separately.

CAUTI: CMS HEN 2.0 Evaluation Measure – All Facilities Urinary Catheter Utilization Ratio

ICUs + Other Inpatient Units

ICUs excluding NICUs

Measure type Process

Numerator

Number of indwelling urinary catheter days for bedded inpatient care locations Denominator Number of patient days for bedded inpatient care locations

Exclusions Level II or III NICU locations

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑢𝑟𝑖𝑛𝑎𝑟𝑦 𝑐𝑎𝑡ℎ𝑒𝑡𝑒𝑟 𝑑𝑎𝑦𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑑𝑎𝑦𝑠



Data source (s) NHSN (Keystone Data System for non-NHSN users) Automatic transfer from NHSN- for hospitals conferring rights to IHA or MHA Keystone Center


Data collection period Monthly, beginning July 2015 KDS Survey Name CAUTI Data Collection KDS Measure ID(s) KDS-HEN-CAUTI-3a (all units)


PfP Measure Name CAUTI_DU_ALL CAUTI_DU_ICU


MHA/IHA HEN 2.0


Central Line-Associated Blood Stream Infection (CLABSI) Standardized Infection Ratio

(SIR)


CLABSI: CMS HEN 2.0 Evaluation Measure – NHSN Reporting Facilities ONLY – NQF 0139 Central Line-Associated Bloodstream Infection (CLABSI) Standardized Infection Ratio (SIR)


ICU: ICUs including NICUs Measure type Outcome Numerator Number of observed infections Denominator Number of predicted infections Exclusions Expected infection count less than one, NICU locations, or no data

reported during baseline period.




Available from CDC NHSN Available from NQF 0139

Data source (s) NHSN (all inpatient locations) Automatic transfer from NHSN- for hospitals conferring rights to IHA or MHA Keystone Center


Data collection period Monthly, beginning July 2015 KDS Survey Name CLABSI SIR (HEN-Quarterly)

KDS Measure ID(s) KDS-HEN-CLABSI-1a (all units) KDS-HEN-CLABSI-1b (ICUs including NICUs)

PfP Measure Name NHSN_CLABSI_ALL_SIR NHSN_CLABSI_ICU_SIR

Notes This measure is only collected for hospitals submitting data to NHSN and conferring rights to IHA or MHA Keystone Center.

Data elements to calculate this ratio will be extracted from NHSN for hospitals which confer rights to IHA or MHA Keystone Center. Hospitals are expected to confer rights to all inpatient locations.

Note: Only those locations for which baseline data have been published will be included in the SIR calculations. For acute care hospitals, the baseline time period is 2006-2008; for long term acute care hospitals and inpatient rehabilitation facilities (IRFs) and IRF units, the baseline time period is 2013.

http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf


MHA/IHA HEN 2.0


Central Line-Associated Blood Stream Infection (CLABSI) Rate

All Facilities

CLABSI: CMS HEN 2.0 Evaluation Measure - All Facilities Central Line-Associated Bloodstream Infection (CLABSI) Rate


ICU: ICUs including NICUs Measure type Outcome Numerator Number of observed healthcare-associated CLABSI among patients in

inpatient care locations

Denominator Number of central line days for each location under surveillance for CLABSI during the data period

Exclusions None

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓𝐶𝐿𝐴𝐵𝑆𝐼

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑒𝑛𝑡𝑟𝑎𝑙 𝑙𝑖𝑛𝑒 𝑑𝑎𝑦𝑠 𝑥 1,000





Data collection period Monthly, beginning July 2015 KDS Survey Name CLABSI Data Collection

KDS Measure ID(s) KDS-HEN-CLABSI-2a (all units) KDS-HEN-CLABSI-2b (ICUs including NICUs)

PfP Measure Name NHSN_CLABSI_ALL_RATE NHSN_CLABSI_ICU_RATE

Data elements to calculate this ratio will be extracted from NHSN for hospitals which confer rights to IHA

or MHA Keystone Center. Hospitals are expected to confer rights to all inpatient locations.

Hospitals not reporting to NHSN are required to report CLABSIs, patient days, and central line days, for all units through MHA Keystone Data System, monthly.


MHA/IHA HEN 2.0


Central Line Utilization Ratio

All Facilities CLABSI: CMS HEN 2.0 Evaluation Measure Central Line Utilization Ratio

ALL: ICUs + Other Inpatient Units

ICU: ICUs including NICUs

Measure type Process Numerator Number of central line days for bedded inpatient care locations Denominator Number of patient days for bedded inpatient care locations Exclusions None

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑐𝑒𝑛𝑡𝑟𝑎𝑙 𝑙𝑖𝑛𝑒 𝑑𝑎𝑦𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑑𝑎𝑦𝑠





Data collection period Monthly, beginning July 2015 KDS Survey Name CLABSI Data Collection KDS Measure ID(s) KDS-HEN-CLABSI-3a (all units)

KDS-HEN-CLABSI-3b (ICUs including NICUs)

PfP Measure Name CLABSI_DU_ALL CLABSI_DU_ICU

Data elements to calculate this ratio will be extracted from NHSN for hospitals which confer rights to IHA or MHA Keystone Center. Hospitals are expected to confer rights to all inpatient locations.

Hospitals not reporting to NHSN are required to report CLABSIs, patient days, and central line days, for all units through the MHA Keystone Data System, monthly.


MHA/IHA HEN 2.0


Surgical Site Infection (SSI) Standardized Infection Ratio (SIR)

NHSN Reporting Facilities ONLY SSI: CMS HEN 2.0 Evaluation Measure – NHSN Reporting Facilities ONLY (NQF 0753) Surgical Site Infection (SSI) Standardized Infection Ratio (SIR)

Colon Surgeries (COLO)

Abdominal hysterectomies (HYST)

Total knee replacements (KPRO)

Total hip replacements (HPRO) Measure type Outcome Numerator Number of observed infections Denominator Number of predicted infections Exclusions Number of predicted infections less than one, or no data reported

during baseline period.





Data source (s) NHSN (all inpatient locations)

Automatic transfer from NHSN- for hospitals conferring rights to IHA or MHA Keystone Center Baseline period Hospital-dependent Data collection period Monthly, beginning July 2015 KDS Survey Name HEN - SSI SIR (HEN-Quarterly)

KDS Measure ID(s) KDS-HEN-SSI-1a (COLO) KDS-HEN-SSI-1b (AB HYS) KDS-HEN-SSI-1c (KNEE) KDS-HEN-SSI-1d (HIP)

PfP Measure Name NHSN_SSI_COLO_SIR NHSN_SSI_HYST_SIR NHSN_SSI_KPRO_SIR NHSN_SSI_HPRO_SIR

Notes This measure is only collected for hospitals submitting data to NHSN and conferring rights to IHA or MHA Keystone Center


Hospitals not reporting to NHSN are required to report SSIs and number of operative procedures, for each of the four procedure categories through the MHA Keystone Data System.

Note: Only those locations for which baseline data have been published will be included in the SIR calculations. For acute care hospitals, the baseline time period is 2006-2008.

http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf

MHA/IHA HEN 2.0


Surgical Site Infection (SSI) Rate

All Facilities SSI: IHA-MHA HEN 2.0 Evaluation Measure Surgical Site Infection (SSI) Rate. Aggregation of following procedures:

Colon Surgeries (COLO)

Abdominal hysterectomies (HYST)

Total knee replacements (KPRO)

Total hip replacements (HPRO) Measure type Outcome Numerator Number of surgical site infections based on CDC NHSN definition Denominator Number of patients having any of the procedures included in the

selected NHSN operative procedure category(s)

Exclusions None

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑆𝑆𝐼𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑜𝑝𝑒𝑟𝑎𝑡𝑖𝑛𝑔 𝑟𝑜𝑜𝑚 𝑝𝑟𝑜𝑐𝑒𝑑𝑢𝑟𝑒𝑠 𝑥 100



Data source (s) NHSN (Keystone Data System for non-NHSN users)



Data collection period Monthly, beginning July 2015 KDS Survey Name HEN - SSI

KDS Measure ID(s) KDS-HEN-SSI-2

PfP Measure Name NHSN_SSI_RATE


Hospitals not reporting to NHSN are required to report SSIs and number of operative procedures, for each of the four procedure categories through the MHA Keystone Data System. These data elements shall be submitted monthly.

http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf

MHA/IHA HEN 2.0


Ventilator-Associated Condition (VAC)

All Facilities with ventilated inpatients VAE: CMS HEN 2.0 Evaluation Measure Ventilator Associated Condition (VAC) Measure type Outcome

Numerator

Number of events that meet the criteria of VAC; including those that meet the criteria for infection-related ventilator- associated complication (IVAC) and possible/probable ventilator-associated pneumonia (PVAP)

Denominator Number of ventilator days Exclusions None

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑉𝐴𝐶𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑣𝑒𝑛𝑡𝑖𝑙𝑎𝑡𝑜𝑟 𝑑𝑎𝑦𝑠𝑥 1,000



Data source(s) NHSN (Keystone Data System for non-NHSN users) Automatic transfer from NHSN- for hospitals conferring rights to IHA or MHA Keystone

Center Baseline period Hospital-dependent

Data collection period Monthly, beginning July 2015 KDS Survey Name VAE KDS Measure ID(s) KDS-HEN-VAE-1 PfP Measure Name VAC

Data elements to calculate this rate will be extracted from NHSN for hospitals which confer rights to IHA or MHA Keystone Center.

Hospitals not reporting to NHSN shall be required to report the number of VACs and number of ventilator days for through the MHA Keystone Data System. These data elements shall be submitted monthly.

http://www.cdc.gov/nhsn/PDFs/pscManual/10-VAE_FINAL.pdf

MHA/IHA HEN 2.0


Infection-Related Ventilator-Associated Complication (IVAC)

All Facilities with ventilated inpatients

VAE: CMS HEN 2.0 Evaluation Measure Infection-Related Ventilator-Associated Complication (IVAC) Measure type Outcome

Numerator

Number of events that meet the criteria of infection-related ventilator-associated condition (IVAC); including those that meet the criteria for Possible/Probable VAP (PVAP)

Denominator Number of ventilator days Exclusions None

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝐼𝑉𝐴𝐶𝑠

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑣𝑒𝑛𝑡𝑖𝑙𝑎𝑡𝑜𝑟 𝑑𝑎𝑦𝑠𝑥 1,000



Data source(s) NHSN (Keystone Data System for non-NHSN users) Automatic transfer from NHSN- for hospitals conferring rights to IHA or MHA Keystone Center


Data collection period Monthly, beginning July 2015 KDS Survey Name VAE KDS Measure ID(s) KDS-HEN-VAE-2 PfP Measure Name IVAC

Data elements to calculate this rate will be extracted from NHSN for hospitals which confer rights to IHA or MHA Keystone Center.

Hospitals not reporting to NHSN shall be required to report the number of IVACs and number of ventilator days through the MHA Keystone Data System. These data elements shall be submitted monthly.

http://www.cdc.gov/nhsn/PDFs/pscManual/10-VAE_FINAL.pdf

MHA/IHA HEN 2.0


Keystone Data System (KDS)

Adverse Drug Event – Excessive Anticoagulation with Warfarin – Inpatients

All Facilities

ADE: MHA/IHA HEN 2.0 Evaluation Measure Adverse Drug Events (ADE) related toAnticoagulation Safety: Inpatients experiencing excessive anticoagulation with warfarin

Measure type Outcome Numerator Number of inpatients experiencing excessive anticoagulation with

warfarin (INR greater than 6) Denominator Number of inpatients receiving warfarin anticoagulation therapy

Exclusions Patients with INR greater than 6, present on admission

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤𝑖𝑡ℎ 𝐼𝑁𝑅 > 6

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑟𝑒𝑐𝑒𝑖𝑣𝑖𝑛𝑔 𝑤𝑎𝑟𝑓𝑎𝑟𝑖𝑛 𝑎𝑛𝑡𝑖𝑐𝑜𝑎𝑔𝑢𝑙𝑎𝑡𝑖𝑜𝑛 𝑡ℎ𝑒𝑟𝑎𝑝𝑦𝑥100


Available from ISMP Trigger Alert List

Data source (s) Hospital Reported: Submit to Keystone Data System (KDS) Automatic transfer from n/a Baseline period October 2015

Data collection period Monthly, beginning July 2015 KDS Survey Name HEN - ADE - Anticoagulation & Glucose KDS Measure ID(s) KDS-HEN-ADE-2

PfP Measure Name INR_6

These data elements shall be submitted monthly by all hospitals to the MHA Keystone Data System. Data can be collected through laboratory systems, pharmacists’ intervention data, medical records or administrative data. Data Collection Tips:

Create/utilize laboratory reports for INRs greater than 6 for inpatients receiving warfarin therapy.

Connect with pharmacists; they may already be collecting this data.

Partner with IT and pharmacy to create electronic reports for real-time monitoring and improvement.

Patients with multiple INRs above threshold during an admission only count as one event.

For purposes of HEN data submission, consider assuming that all high INRs are from patients receiving warfarin. The lab should be able to provide the numerator and pharmacy can provide the denominator. Be sure to keep your data collection metrics and scope consistent through the year.

If collecting house-wide data is not currently possible, focus on collecting data from just those units where warfarin is most often administered, and then work towards collecting house-wide.

http://ismp.org/newsletters/acutecare/articles/20050310_2.asp

MHA/IHA HEN 2.0


Adverse Drug Event – Hypoglycemia in Inpatients Receiving Insulin All Facilities

ADE: MHA/IHA 2.0 Evaluation Measure – All Facilities Adverse Drug Events (ADE) related to Glycemic Management: Hypoglycemia in inpatients receiving insulin

Measure type Outcome Numerator Hypoglycemia in inpatients receiving insulin or other hypoglycemic agents as

warranted (e.g. hypoglycemia defined as plasma glucose concentration of 50 mg per dl or less).

Denominator Inpatients receiving insulin or other hypoglycemic agents identified as warranted

Exclusions Patients with hypoglycemia present on admission

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤𝑖𝑡ℎ ℎ𝑦𝑝𝑜𝑔𝑙𝑦𝑐𝑒𝑚𝑖𝑎 𝑤ℎ𝑜 𝑎𝑟𝑒 𝑟𝑒𝑐𝑒𝑖𝑣𝑖𝑛𝑔 𝑖𝑛𝑠𝑢𝑙𝑖𝑛

𝑎𝑛𝑑 𝑜𝑡ℎ𝑒𝑟 ℎ𝑦𝑝𝑜𝑔𝑙𝑦𝑐𝑒𝑚𝑖𝑐 𝑎𝑔𝑒𝑛𝑡𝑠 𝑎𝑠 𝑤𝑎𝑟𝑟𝑎𝑛𝑡𝑒𝑑𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑟𝑒𝑐𝑒𝑖𝑣𝑖𝑛𝑔 𝑖𝑛𝑠𝑢𝑙𝑖𝑛 𝑎𝑛𝑑 𝑜𝑡ℎ𝑒𝑟 ℎ𝑦𝑝𝑜𝑔𝑙𝑦𝑐𝑒𝑚𝑖𝑐

𝑎𝑔𝑒𝑛𝑡𝑠 𝑎𝑠 𝑤𝑎𝑟𝑟𝑎𝑛𝑡𝑒𝑑

𝑥 100


Available from ASHP Safe Use of Insulin

Data source (s) Hospital Reported: Submit to MHA Keystone Data System (KDS)

Automatic transfer from n/a Baseline period October 2015

Data collection period Monthly, beginning July 2015 KDS Survey Name HEN - ADE - Anticoagulation & Glucose KDS Measure ID(s) KDS-HEN-ADE-3

PfP Measure Name

BG_50

These data elements shall be submitted monthly by all hospitals to the MHA Keystone Data System. Data can be collected through laboratory systems, pharmacists’ intervention data, medical records or administrative data.

Data Collection Tips:

Partner with pharmacy, laboratory staff and/or Information Technology.

Connect with pharmacists or Endocrine service as they may already be collecting this data.

Create/utilize laboratory/glucometer/EHR hypoglycemia documentation reports for blood glucose levels of 50 mg/dL or less.

Implement a notification process: identifying paper/stickers attached to IV Dextroxe 50% bags or Glucagon for periodic retrieval.

Patients with multiple blood glucose levels 50 mg/dL or less during an admission count only once.

Consider focusing only on hypoglycemia associated with insulin as the hypoglycemic agent – make sure to consistently report in this manner throughout the year

If collecting house-wide data is not currently possible, focus on collecting data from just those units where insulin is most often administered, and then work towards collecting house-wide.

http://www.ajhp.org/content/70/16/1404.full.pdf?hw-tma-check=true

MHA/IHA HEN 2.0


Adverse Drug Event – ADEs due to Opioids All Facilities

ADE: MHA/IHA HEN 2.0 Evaluation Measure – All Facilities Adverse Drug Events (ADE) related to Opioids: Patients receiving naloxone after treatment with IV opiods

Measure type Outcome Numerator Number of patients treated with an IV opioid who received naloxone

Denominator Number of patients who received an IV opioid Exclusions Obstetrics and Emergency Department

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤𝑖𝑡ℎ 𝐼𝑉 𝑜𝑝𝑖𝑜𝑖𝑑 𝑤ℎ𝑜 𝑟𝑒𝑐𝑒𝑖𝑣𝑒𝑑 𝑛𝑎𝑙𝑜𝑥𝑜𝑛𝑒

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑠 𝑤𝑖𝑡ℎ 𝐼𝑉 𝑜𝑝𝑖𝑜𝑖𝑑𝑠 𝑥 100


Available from MHA Keystone: Pain Management

Data source (s) Hospital Reported: Submit to the MHA Keystone Data System (KDS) (Also a measure for the Keystone: Pain Management collaborative)

Automatic transfer from n/a Baseline period October 2015

Data collection period Monthly, beginning July 2015 KDS Survey Name Pain Management KDS Measure ID(s) KDS-HEN-ADE-4

PfP Measure Name narcan_admin

These data elements shall be submitted monthly by all hospitals to the MHA Keystone Data System.

Data can be collected through laboratory systems, pharmacists’ intervention data, medical records or administrative data.

Data Collection Tips:

Partner with pharmacy, procedural area staff and/or Information Technology. Connect with pharmacists as they may already be collecting this data.

Implement a notification process: identifying paper/stickers attached to naloxone vials for periodic retrieval.

Multiple doses of naloxone to the same patient during a hospital stay count as one event.

Consider non-traditional data collection sources: rapid response team event reports, medication dispensing cabinet reports, RASS or MOSS sedation assessment documentation.

If collecting house-wide data is not currently possible, focus on collecting data from just those units where IV opioids are most often administered, and then work towards collecting house-wide.

MHA/IHA HEN 2.0


Falls with Injury (NQF 0202)

All Facilities

Falls: CMS HEN 2.0 Evaluation Measure (NQF 0202) All Documented Patient Falls with an Injury Level of Minor or Greater Measure type Outcome

Numerator Number of patient falls of injury level minor or greater (whether or not assisted by a staff member) in eligible units.*

Denominator Number of patient days in eligible units during the measurement period

Exclusions Non-eligible unit types: pediatric, psychiatric, obstetrical, etc.

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑓𝑎𝑙𝑙𝑠 𝑤𝑖𝑡ℎ 𝑖𝑛𝑗𝑢𝑟𝑦

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑎𝑡𝑖𝑒𝑛𝑡 𝑑𝑎𝑦𝑠𝑥 1,000


Available from NQF 0202

Data source (s) Hospital Reported: Submit to MHA Keystone Data System (KDS) Automatic transfer from n/a Baseline period 2014

Data collection period Monthly, beginning July 2015 KDS Survey Name Falls Data Collection KDS Measure ID(s) KDS-HEN-Falls-1 PfP Measure Name Falls_Injury


The total patient days can be collected from billing systems.

The number of patient falls can be collected from electronic clinical data or medical records, fall surveillance systems, injury reports, event tracking systems or other similar sources.

*Eligible units include adult critical care, step-down, medical, surgical, medical-surgical combined, critical access, adult rehabilitation in-patient.


MHA/IHA HEN 2.0


Early Elective Delivery (EED)

All Facilities with OB services

EED: CMS HEN 2.0 Evaluation Measure (PC-01, NQF 0469) Patients with Elective Vaginal Deliveries or Elective Cesarean Sections at >=37 and <39 Weeks of Gestation Completed Measure type Process

Numerator Number of patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed

Medical induction of labor as defined in the Joint Commission Manual

Cesarean section as defined in the Joint Commission Manual and all of the following: o Not in labor o Not experiencing spontaneous rupture of membranes o No history of a prior uterine surgery

Denominator Number of patients delivering newborns with >=37 and < 39 weeks of gestation completed Exclusions Diagnosis codes for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A (see source documents)

Rate calculation

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑙𝑒𝑐𝑡𝑖𝑣𝑒 𝑑𝑒𝑙𝑖𝑣𝑒𝑟𝑖𝑒𝑠 𝑏𝑒𝑡𝑤𝑒𝑒𝑛 37 − 39 𝑤𝑒𝑒𝑘𝑠 𝑔𝑒𝑠𝑡𝑎𝑡𝑎𝑖𝑜𝑛

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑑𝑒𝑙𝑖𝑣𝑒𝑟𝑖𝑒𝑠 𝑏𝑒𝑡𝑤𝑒𝑒𝑛 37 − 39 𝑤𝑒𝑒𝑘𝑠 𝑔𝑒𝑠𝑡𝑎𝑡𝑖𝑜𝑛𝑥100


Available from the Joint Commission Manual: PC-01 Available from NQF 0469

Data source (s) Hospital Reported: Submit to MHA Keystone Data System (KDS) (or OB Portal for Keystone: OB Hospitals)

Automatic transfer from n/a Baseline period 2013

Data collection period Monthly, beginning July 2015 KDS Survey Name HEN - OB EED & PPH KDS Measure ID(s) KDS-HEN-OB-5 PfP Measure Name PC_01


Numerator and denominator data may be available from billing systems, medical records or other similar sources.

https://manual.jointcommission.org/releases/TJC2013A/MIF0166.html



https://manual.jointcommission.org/Manual/WebHome


MHA/IHA HEN 2.0


Post-Partum Hemorrhage (PPH)

All Facilities with OB services OB: MHA/IHA HEN 2.0 Evaluation Measure – All Facilities with OB services Women (who gave birth > 20 0/7 weeks gestation) who were transfused with ≥4 units of any blood

product during the birth


Numerator Number of women (who gave birth > 20 0/7 weeks gestation) who were transfused with ≥4 units of any blood product during the birth admission. See included codes below. Denominator Number of women giving birth (>20 0/7 weeks gestation)

Exclusions Only include women who have delivered (either vaginal or cesarean)

and received a transfusion as a result of the delivery. All other

instances would be exclusions e.g. transfusions for co-morbidities,

other disease processes, or trauma.

Rate calculation 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑤𝑜𝑚𝑒𝑛 𝑡𝑟𝑎𝑛𝑠𝑓𝑢𝑠𝑒𝑑 𝑤𝑖𝑡ℎ ≥ 4 𝑢𝑛𝑖𝑡𝑠 𝑜𝑓 𝑏𝑙𝑜𝑜𝑑 𝑑𝑢𝑟𝑖𝑛𝑔 𝑏𝑖𝑟𝑡ℎ

𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑤𝑜𝑚𝑒𝑛 𝑔𝑖𝑣𝑖𝑛𝑔 𝑏𝑖𝑟𝑡ℎ𝑥100


Available from TJC/ACOG/CMQCC

Data source (s) Hospital Reported: Submit to MHA Keystone Data System (KDS) (or OB Portal for Keystone: OB Hospitals)

Automatic transfer from n/a Baseline period 2015

Data collection period Monthly, beginning July 2015 KDS Survey Name HEN - OB EED & PPH KDS Measure ID(s) KDS-HEN-OB-6

PfP Measure Name PPH


Numerator and denominator data may be available from billing systems, medical records or other similar sources.

Numerator: ICD-9-CM: V27.0-V27.9; 666.02; 666.12; 666.22

ICD-10-CM: Z370-Z375: Z3750-Z3754; Z3759; Z376: Z3760-Z3764; Z3769; Z377; Z379; O720-O722

http://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_Six_Sep_2014_FINAL.pdf

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